Foundations HHSRS Training, Starts 17 May 2022
Britain is traditionally a nation of bathers, and although the concept of showering is gaining in popularity, many people still far prefer a bath. But for people with mobility problems who cannot safely manage a bath, a shower adaptation will usually become the preferred option. For some a shower over a bath will be suitable, and for others the easiest way to provide a shower is to simply install a standard tray. But this will still leave a 150-200mm step to negotiate.
An assessment will be required by an Occupational Therapist (or a supervised Trusted DFG Assessor), who will have knowledge of the user’s physical capabilities and their longer term prognosis.
In many cases the only solution is to remove the bath and provide a level access shower area.
The shower area
The traditional three foot square shower cubicle with a step down or raised base is outmoded and impracticable for most. Ideally there should be no changes in floor level between the shower area and that adjoining it apart from a minimum fall to carry the water to an outlet. There should be no fixed screen walls or partitions enclosing it.
Where a shower area is provided for a disabled person, it is normal for Social Services to provide a wheelchair to be exclusively used while showering. This allows dressing and undressing to take place within the bedroom, so decreasing the space required within the shower room – essential where an standard size bathroom is being converted.
For economic use of floor space, the drainage from a shower should be so devised as to enable the shower area to form part of the circulation space within the room. Where there is a screeded concrete floor, the whole of the shower area could be laid to a slight fall (between 1:20 and 1:40) towards a round gully with its grating set flush with the lowest point. To prevent any water flooding out through the door it is preferable for the gully to be positioned on the opposite side of the room.
Vinyl sheet or ceramic tiles provide an acceptable floor finish, so long as they incorporate non-slip properties. Carpet should be avoided as it does not dry or clean so readily and also makes wheelchairs more difficult to manoeuvre.
Continuous gratings around a shower area are not recommended as they can be easily dislodged creating a hazard for the ambulant disabled and possibly interfere with the movement of a wheelchair.
Where the floor construction restricts or prevents the necessary fall to the drainage outlet one of a wide range of level access shower trays may provide a suitable solution. Trays are available in all shapes and sizes, making careful selection very important.
For a traditional boarded timber joist construction, one of the best solutions is to cut out the floorboards and use a shower former set down onto the joists. Vinyl sheet with welded seams is the laid across the whole floor to prevent any water leaks.
Where floorboards cannot be so easily cut away or below floor drainage is not available there are many glass fibre trays available that require little or no excavation of the existing floor. Such trays usually include a small ramp on entry in order to prevent the escape of water, but may be a potential obstruction to circulation.
The ideal shape of tray for a wheelchair user is a minimum of 1.0m square, with 1.2m being preferred. Bath-shaped trays for easy replacement of baths are available although a standard bath width of 700mm is not usually sufficient for most users. Smaller trays are available for ambulant users.
Where it is impossible to excavate any of the floor, even for drainage pipes there are two possible options – to use a tray with shallow steps up to the shower area where the user is able to manage them; or to use a water pump.
A pump may be used to suck up water from glass fibre tray and transfer it to the waste outlet. Although not an ideal solution, a pump may also be useful where the shower area is remote from main drainage runs.
In order to reduce splashing, which tends to increase hazards by unnecessarily extending the wet area of the floor, curtains hung on runners should be provided that can be pulled out of the way when the shower is not in use. To prevent water escape the curtains should trail to the floor, which will necessitate a longer than average drop to allow the rail to be sited above head-height. Weighted hems will also assist with the retention of water.
Where the disabled person requires assistance in the shower, half-height glazed screens may be installed to prevent the carer from taking taking the shower as well.
The shower control
The control of the flow of warm water must be within easy reach of the user’s sitting position, but placed so as not to be an obstruction. For some users two shower sprays are essential, the first to play warm water over the body and the second for more detailed washing.
A thoroughly reliable thermostatic mixing valve is essential and for those with skin acutely affected by temperature change, extra sensitive thermostat elements should be specified. It is also important that the valve should stop the flow of all of the water and not just the hot as a blast of cold water may be just as bad.
A shower rose and flexible hose mounted on an adjustable vertical rail should be provided within easy reach and without obstructing movement.
Several manufacturers produce a package designed for disabled users including extended riser rail and hose to allow use by disabled and able-bodied users as well as an extended lever for the heat control.
The water closet (toilet)
The main criteria when specifying a w.c. is the height of the seat. For a wheelchair user the seat should ideally be the same height from the floor as that of the wheelchair (i.e. around 510mm), whereas a normal height pan will normally suffice for most ambulant disabled users. For those suffering from stiff or painful joints and find it impossible to lower and raise themselves from a standard toilet, supplementary seats are available to raise the level as required.
If a particular seat height is required then a cantilevered pan may be preferable so long as particular consideration is given to the careful detailing of supports. Otherwise a shaped timber plinth secured beneath a normal pedestal pan should be quite adequate.
The space required around the w.c. will again depend on the user. An ambulant disabled user generally prefers supporting rails close by whereas a wheelchair user needs space to manoeuvre alongside. The approach and space required for any wheelchair user will be specific and the advice of an Occupational Therapist will be required.
While a close coupled suite may be considered the more attractive, a separate pan and cistern with connecting flush pipe is far more adaptable. Both the horizontal and vertical distances between the pan and cistern can be easily varied to suit the user, and where space is tight a high-level cistern with flush chain can be used to great effect.
The toilet seat
The strength, material and shape of the toilet seat are important considerations. If the disability is not too severe a standard plastic seat will be acceptable, so long as there are no accentuated raised edges that may impede transfer.
A more severely disabled user will generally have less control of their body weight, and a sudden impact on the seat must therefore be anticipated. The stresses sustained from a horizontal wheelchair transfers on units designed to accept weight from a vertical position may also be excessive. Some also find the normal ring seat insufficiently wide, and visually insecure, to use as a hand rest when transferring.
The wash basin
Particular care needs to be taken in selecting wash basins. Some models reputed to have been specifically designed for the disabled have been found to be quite unsuitable in practice.
When selecting a basin for a wheelchair user, two important requirements must be met. Firstly the arms of a wheelchair should not prevent the user from getting sufficiently close to the basin; and secondly, the front of the basin must be an adequate distance from the back wall to allow for projecting footrests and feet. This obviously makes the use of pedestal supports unsuitable.
Whatever the user’s disability, the provision of space around the basin will allow its use as dressing table space for shaving, hairdressing and make-up and provide ready access to toiletries. If there is space available, a vanity bowl set into a formica faced blockboard sheet of appropriate size is ideal.
The height that the basin is set to is crucial to its utility; in most cases this should be agreed with the user during fitting. Where there is likely to be a requirement to adjust the height over time, an adjustable fitting may be considered with flexible couplings to the taps and waste..
Where greater flexibility is needed, there are basins available which are fitted with hydraulic rams that allow the user to adjust the height at the touch of a button. This is very useful if there are multiple users or where a single user alternates between using a chair and standing.
The bidet offers those whose disability prevents them from being fully able to cleanse themselves, the ability to do so with some independence and dignity.
The standard bidet is, however, normally too low to allow direct transfers for wheelchair users; requiring the whole unit to be raised on a base. Due to the use of hot water around particularly sensitive areas, thermostatic control of the water temperature should also be included.
A modern alternative to the traditional bidet is the combined w.c. and bidet, which can include remote control and warm air drying facilities. On most models a spray head is positioned beneath the user when required and retracts after use. Complete units or conversion kits for existing toilets are available.
Heating, lighting & ventilation
As most disabled people feel the cold more than the able-bodied, the bathroom of a disabled person should always have the provision for the maintenance of a comfortable room temperature. This is particularly important in the shower area. Where mechanical ventilation is used, radiant heat sources are recommended.
In order to prevent a build up of steam while the shower is in use and to keep the room free of condensation and mould growth, it is important to install an adequate ventilation system. Use of wall, window or ceiling mounted mechanical extract fans is advisable, either controlled by a humidistat or connected into the light switch.
Fans should be carefully positioned so as to provide the maximum amount of air circulation within the room. As most air will be sucked in under the door, the fan should be positioned in the opposite corner of the room. If this brings the fan within the vicinity of the shower a low-voltage unit should be installed.
Due to the amount of steam generated by a shower, a sealed light unit should always be installed. Florescent or LED fittings provide a long life-span and reduced consumption.
It is important to protect the walls surrounding showers and wash basins from water penetration. Ceramic tiling is usually the most appropriate solution. White tiles are cheapest but look quite clinical. There is a wide variety of other colours and patterns available within a budget.
Where the user is, or may be, visually impaired, a contrast should be sought between the sanitaryware, the walls and the floor, so necessitating the use of more colourful tiling.